If you have worked in any health care system, you have almost certainly heard these phrases uttered during your work experience:

“That’s how it’s always been done.”

“That’s what the surgeon likes.”

“But your colleagues do it that way.”

“If it’s not broke, don’t fix it.”

Sometimes these phrases can be quite helpful; for example, when joining one’s first practice as a new graduate from residency. With no experience working on your own, choosing an anesthetic plan may be easier with a preset template to follow. Asking one’s colleagues how they perform sedation for their interventional radiology cases, or how they manage postoperative pain after joint replacements, may easily help a new anesthesiologist craft a successful anesthetic plan. Mimicking one’s colleagues and their behaviors or templates for care may provide comfort and integrate you into the new team.

Pretty soon into a career, however, it is not unusual to want to practice differently from “what everyone else does” – that is, to take all the clinical knowledge you have learned over the years and practice in a way you think will provide best care for your patients. Most of the time it will not be an issue if you want to give different sedating medications or to use an adductor canal block instead of a femoral approach. However, a practitioner may sometimes run up against a wall that seems like an intractable object standing in the way of patient care. Before ultrasounds were the standard of care, new graduates who had trained utilizing ultrasound may have had to fight skepticism when they joined a group where most clinicians still used a landmark technique for nerve blocks. They may have heard, “That’s not what we do here” when requesting funding to purchase costly ultrasound equipment. Consider a different example: for a group in which most anesthesiologists use sedation for extracorporeal shockwave lithotripsy cases, a young anesthesiologist may confront skeptical colleagues when using general anesthesia with a laryngeal mask airway. This phenomenon is not unique to new attendings; experienced anesthesiologists may encounter the same challenges in resistance to new practices when taking a new job or working at a new facility.

These aforementioned scenarios were significantly affected by a phenomenon known as cultural or organizational inertia. Culture change in an organization may be routinely impeded by factors such as inadequate or inappropriate leadership, constraints from outside stakeholders or regulations, lack of ownership, and subcultural diversity within a health care system (Int J Qual Health Care 2003;15:111-8).

Why does cultural inertia occur in a workplace? Over time, to complete a set of tasks, a group of workers tends to adopt a set of procedures and rules of behavior that allow for optimal task completion (The Journal of Law, Economics, & Organization 2007;23:743-71). When a belief takes hold that those behaviors and procedures are optimized for the workers and tasks, changes made to that system can be a shock to the participants. Those beliefs have become the organization’s culture.

Further, there can also be a perception that all the time and effort that went into perfecting the organization’s original behaviors and procedures will be lost if the systems are changed. There may also be fear among the workers that if they cannot adapt to a new system, they may be replaced with candidates who can better adapt to a different system.

It is important to consider that culture is generally passed along between people; in a health care setting, it is exchanged between coworkers. Many behaviors, habits, and beliefs are shared among clinical colleagues, becoming embedded in daily activities. When an organization becomes homogenous in those behaviors or beliefs, it becomes very difficult, or impossible, to adapt and change. Organizations that are more adaptable tend to have heterogeneity in their underlying culture, with some members naturally able to adapt more quickly, often serving as test cases for widespread change for the larger cohort. Data reinforces this dynamic for the wider group, including skeptics. A telling example can be found in enhanced recovery after surgery (ERAS) programs, which demonstrate marked improvement in clinical quality and financial expenditures, leading to growing implementation among clinicians (JAMA Surg 2017;152:292-8).

When does cultural inertia shift in impact from a mere nuisance for an individual to systemic impact? Change is the one constant in health care, and it impacts anesthesiology with regular frequency. From new documentation requirements to changes in medication handling, and from advanced approaches for nerve blocks to ever-evolving regulatory standards, anesthesia providers feel pressure to change habits on a regular basis. Often these changes are mandated by one’s practice, department, group, hospital, health care system, regulatory agency, medical facility, or professional society. However, even with small changes, cultural resistance may prevent successful implementation of needed modifications, hindering compliance with important standards, affecting perioperative efficiency, compromising patient care, or even decreasing practice revenue.

Although cultural inertia may be difficult to overcome, strategies may be used by anesthesia groups to facilitate the necessary change. Leaders should strive to promote a culture of continuous improvement; this lies in contrast to abrupt changes that are often viewed with reflexive initial resistance (asamonitor.pub/49Mr3ql). Leaders may foster this forward-thinking culture by creating engaging educational programs that promote advancements in perioperative medicine in an accessible manner. Backing research initiatives and using evidence-based outcomes can help a group of clinicians to evaluate, implement, and adopt new interventions. Continuing medical education (CME) has been demonstrated in numerous reviews to improve health care outcomes, reinforcing the understanding that evidence-based data modifies and improves clinician practice (J Contin Educ Health Prof 2015;35:131-8).

Numerous models exist for explaining a group’s response to change or a potential shift in culture. One such model demonstrated by Paul Selivanoff in literature from the Healthcare Financial Management Association argues that there are four stages of change, which are likened to the grieving process: denial, resistance, exploration, and commitment (Figure 1) (asamonitor.pub/43cFiCa). Denial represents a stage in which affected personnel minimize the need for a change, refuse to assimilate new information, and revert to their “usual” behaviors. During resistance, there may be anger, stubbornness, or a willingness to blame others for an undesired outcome. The exploration phase may include seeking of alternatives to a proposed change, clarifying goals of the change, or learning new skills. Finally, commitment occurs when teamwork prevails, the vision is effectively communicated, and cooperation is ultimately achieved.

Figure 1: The four stages of response to change (adapted from Selivanoff P. 2018) (asamonitor.pub/43cFiCa).

Figure 1: The four stages of response to change (adapted from Selivanoff P. 2018) (asamonitor.pub/43cFiCa).

To successfully progress from denial to commitment, it is important to consider a multipronged approach to wholesale culture change. In their book “Switch: How to Change Things When Change Is Hard,” Chip Heath and Dan Heath argue that change requires intellectual, emotional, and environmental components (Figure 2) (How to Change Things When Change Is Hard. 2010). Intellectual interventions may involve scripting specific behaviors and elucidating the desired endpoints of a new expectation. Emotional components to change may involve leaders demonstrating a new mindset to colleagues or explaining the underlying motivations behind a change. Finally, environmental changes are implemented to make the desired behaviors easier for participants, such as checklists, modifications to electronic health records, or requiring new steps in a workflow.

Figure 2: The three pillars of change management for a group of clinicians (adapted from Heath C. et al 2010) (How to Change Things When Change Is Hard. 2010).

Figure 2: The three pillars of change management for a group of clinicians (adapted from Heath C. et al 2010) (How to Change Things When Change Is Hard. 2010).

Additionally, it is very important to consider a group’s incentive structure. Incentives may be both positive (increase income, bonus, public praise, improved metrics, etc.) or negative (absence of bonus, negative feedback on evaluations, etc.). Incentives help to alter behavior by either providing goals to pursue, such as quality-based bonuses, or avoidance of undesired outcomes. It is indisputable that culture not only affects patient outcomes but also clinician satisfaction and well-being. When change is needed for a group of clinicians, steps must be taken to ensure that cultural inertia does not impede forward progress.